7 Steps to Check If Telehealth Primary Care Is Covered

How I approach this guide: evidence-based practice

Insurance questions are not clinical questions, but confusing costs should never be the reason you put off care. My goal with this guide is to make the coverage check simple and predictable, so the paperwork does not stand between you and your health.

Like everything on this blog, this guide follows evidence-based practice: finding and appraising the best available research, then applying it together with clinical expertise and each patient's own values and preferences.³ Health systems that use evidence-based practice see better patient outcomes.⁴ Each research-based statement below is linked to a peer-reviewed study published within the last five years, and the numbered references are at the end of the article. Insurance rules themselves change often, so your plan documents and your insurer always have the final word on your benefits.

Why telehealth primary care coverage varies from plan to plan

Telehealth use grew dramatically during the COVID-19 pandemic because of temporary waivers and flexibilities tied to the public health emergency.¹ Since then, lawmakers, regulators and insurers have kept revising the rules, and the future of some coverage has depended on further government action.^1,5

For private insurance, many states have their own telehealth laws. These generally come in two types:²

• Coverage parity: the plan must cover a service when it is delivered by telehealth if it covers that service in person.
• Payment parity: the plan must pay for telehealth on the same basis as an in-person visit.

Not every state has both, and the details differ from state to state.² On top of state rules, each plan has its own network, cost-sharing and referral requirements. That is why two people with insurance from the same company can get different answers to the same question.

Understanding all of this takes what researchers call health insurance literacy: the knowledge, ability and confidence to find and understand insurance information and use a plan.⁶ If you find insurance language confusing, you are not alone. The steps below are designed to make it manageable.

7 steps to check if telehealth primary care is covered

Set aside about 15 minutes and have your insurance card, a pen and the name of the practice you would like to see.

Step 1: Contact your insurer

Call the member services number on the back of your insurance card, or sign in to your plan's member portal or app. Many plans also let you download a "Summary of Benefits and Coverage" document to keep.

Step 2: Ask whether video primary care visits are covered

Be specific. Ask: "Does my plan cover primary care visits by live video with a nurse practitioner?" Naming the exact type of visit helps the representative give you an accurate answer.

Step 3: Check the network

Ask whether the clinician must be in-network, and whether your plan offers any out-of-network benefits. Give the representative the practice name and the clinician's name so they can check directly. Out-of-network care is a common source of surprise bills.⁷

Step 4: Ask about your costs

Ask what you would pay for the visit: your copay (a flat amount), your coinsurance (a percentage) and how much of your deductible you have left this year. If you have not met your deductible, you may pay the full allowed amount for the visit.

Step 5: Ask about referrals and prior authorization

Some plans require a referral from an assigned primary care clinician or advance approval for certain services. Ask whether either applies to a new primary care relationship by telehealth.

Step 6: Confirm where you are located for the visit

Telehealth clinicians generally need to be licensed in the state where you are located during the visit, and cross-state practice limits are one reason telehealth access differs between states.² Ask your insurer whether your plan has any location rules for telehealth, and plan to take your visit from a state where your clinician is licensed.

Step 7: Document everything

Write down the date and time of the call, the representative's name and the call reference number. If you later receive a bill that does not match what you were told, these notes make an appeal much easier.

If you have Medicare

Medicare's telehealth rules expanded through temporary flexibilities during the COVID-19 public health emergency, and whether those flexibilities continue has depended on action by Congress and federal agencies.¹ Because these rules can change from year to year, check current coverage at Medicare.gov, call 1-800-MEDICARE, or call your plan before you book.

If you have a Medicare Advantage plan, the plan must cover the telehealth services that traditional Medicare covers and can choose to offer additional telehealth benefits.⁸ Those extra benefits vary by plan and may be limited to in-network clinicians, so ask your plan directly.

If you have employer or individual insurance

For employer plans and individual marketplace plans, your state's telehealth laws and your plan's own rules both matter.² A few practical tips:

• Ask about video visits with your own clinician, not just a plan-sponsored virtual service. Some plans treat these differently.
• Ask your HR or benefits office whether your state's telehealth rules apply to your employer plan. Not every plan is regulated the same way, and they can confirm which rules apply to yours.
• Look at your deductible. With a high-deductible plan, you may pay the full allowed amount until you meet your deductible, even when telehealth is a covered service.

Understanding what you will pay

Coverage is only half the question. The other half is your out-of-pocket cost. Here are the terms you are likely to hear:

• Copay: a fixed amount you pay for a visit.
• Coinsurance: a percentage of the allowed amount you pay after meeting your deductible.
• Deductible: the amount you pay each year before your plan starts sharing costs for many services.
• Allowed amount: the price your plan has agreed to for a service with in-network clinicians.

The federal No Surprises Act and related state laws were designed to protect patients from certain unexpected out-of-network bills, though the rules are complex and still evolving.⁷ If you are paying yourself, ask the practice for its self-pay price in writing before the visit. Clear prices up front are one of the advantages of a self-pay option.

Is a video visit right for your concern?

Research on primary care telemedicine is encouraging. A systematic review found that, compared with face-to-face care, telemedicine visits in primary care were followed by similar or fewer emergency department and hospital visits, although the authors cautioned that study quality limits firm conclusions.⁹ Another systematic review found that, for diabetes, high blood pressure and high cholesterol, synchronous telemedicine was not inferior to in-person primary care visits, though few studies were available.¹⁰

Telehealth is not right for every situation. Professional guidance recommends using telemedicine for appropriate concerns, choosing the visit type through shared decision-making between patient and clinician, and combining it with in-person care when needed.¹ Some problems need a hands-on exam, lab work, imaging or a procedure. A telehealth clinician can help you decide what you need and where to get it.

Telehealth primary care at Tonies Health

I'm Lucas Tonies, MSN, APRN, FNP-C, CCRN, a board-certified family nurse practitioner with 17 years of critical care nursing experience. I offer telehealth primary care by secure video visit in California and eight other states: Arizona, New Mexico, Wyoming, Washington, Florida, Virginia, Ohio and New York. See states we serve for details. Visits are available in English and Spanish (se habla español).

Insurance and coverage details are confirmed in the patient portal when you book. Medicaid is not accepted. If you prefer to pay yourself, self-pay prices are listed up front:

• New Patient Visit: $150
• Simple Visit: $150
• Weight Loss Consultation: $150
• Visit for 2–3 concerns: $200
• Complex Visit: $250
• Work or medical note: $150

See pricing for the full details. Any treatment plan, including whether a medication is appropriate, depends on an individual evaluation. Questions before you book? Call (415) 373-6466.

Book through the new patient portal

Frequently asked questions

Is telehealth primary care covered by insurance?

Often, but not always. Coverage depends on your plan, your state's telehealth laws and the type of visit, and those rules have changed several times since 2020.^1,2 Call your insurer or check your member portal before you book.

Does Medicare cover telehealth primary care visits?

Medicare's telehealth coverage expanded through temporary flexibilities during the COVID-19 public health emergency, and its future has depended on further action by lawmakers.¹ Medicare Advantage plans must cover the telehealth services traditional Medicare covers and may offer more.⁸ Check Medicare.gov or call your plan for current rules.

Is a telehealth visit as good as an in-person primary care visit?

For many routine concerns and some chronic conditions, research shows similar results, though the evidence base is still limited.^9,10 Some problems need a hands-on exam or testing, so telehealth works best as part of a plan that includes in-person care when needed.¹

What should I do if my insurance won't cover a telehealth visit?

Ask the practice for its self-pay price in writing before the visit, and compare it with what you would owe under your deductible. If you believe a claim was denied in error, use your call notes to appeal with your insurer. Out-of-network bills are a common source of surprise costs, so confirm network status first.⁷